= Menu



Free Blank Medical Records Request Letter Form


A template to be used when requesting copies of medical records from your doctor's office.




Medical Records Request Template



Medical Records Request Letter


[Your Name]
[Address]
[City, State, Zip]



[Date of letter]

[Name of Care Provider or Facility]

[Address]

[City, State, Zip]


Dear [Recipient's name],

I am writing you to request copies of my medical records. I was treated in your office on [xx/xx/xxxx]. Please include all of my charts, test results, and consultation notes including referrals regarding my medical care.

I understand I may be charged a fee that is reasonable for the copying of my medical records, however, I will not be charged for any time that is spent locating my records.

Please mail the requested information to me at the address listed above. I have enclosed a self-addressed envelope for your convenience. I understand that I will be charged for postage.

Best regards,

[Your signature]

[Your name printed]


Note: Under HIPAA guidelines you may be charged for a reasonable fee for copying records. You may also be charged for postage if you request that records be mailed to you. HIPAA allows thirty days for a provider to respond to your request for records, with one thirty day extension for good reason. Your specific state laws may include a lower fee for copies of records or a shorter time for the provider to respond to your request.





Word

PDF




Organize & Communicate


Write & Print A Letter


Letter For Change of Address


Apology Letter To Customer


Letter To Employees About Coronavirus



Thank You Letter


Thank You Letter For Donation


Thank You Letter For Interview


Thank You Letter For Job Offer


Thank You Letter After Meeting


Thank You For Letter Of Recommendation



Miscellaneous


Letterhead Template


Blank Memo


Random Excuse


Fax Cover Sheet


Binder Cover


Daily To Do List


Business Daily Journal


Petition Template


High School Reunion Program


Family Reunion Registration


Conference Registration


Change Request Form


Late Fee Notice


Donation Request Form


Work Log Books


Maintenance & Repair


Church & Weddings


Restaurant



Medical


Letter Requesting Medical Records


Patient Medical Information Sheet


Patient Discharge



Other


Blank Organizational Template


Event Planning



What's New


Letter To Employee About Coronavirus



Search